Water and Sewer Fee Application Applicant Name (entity requesting service): Phone No.:Email Address of Applicant: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address of Property to be served: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Zoning Application: Inside Martinsville City Limits: YES NO Single-family or two-family, dwelling 5/8" meter requested: YES NO Describe Use, including but not limited to: retail sales; general office; restaurant; including fast or carry out foods; grocery; convenient store; gasoline station; professional office, doctor, dentist, clinic, hospital or nursing home; barber or beauty shop; service club, church, civic or fraternal organization; school, college, daycare or library; stage or movie theater; hotel. motel, apartments (more than four units); assisted living or retirement center; car wash; self service laundry; correctional facility; jail or prison; industrial, manufacturing, warehousing, service or repair, dry cleaners, body shop, engine repair, brake/muffler, computer, electronics, contractors, or appliances; recreational facility, picnic areas, campground, racetrack, sport park, open-air stage. IF MULTIPLE USE DESCRIBE ALL USES!Size of Water Meter requested: 5/8" 1" 1- 1/2" 2" 4" 6" 8" Number of restrooms: Number of fire hydrants on private property: If fire service connection required circle size: 4" 6" 8" Automatic Sprinkles: YES NO Kitchen facilities: YES NO A bar or bar area: YES NO Shower or shower facilities: YES NO Seating capacity for restaurant, theater, church, service club: Number of chairs, beds, exam tables (barber, beauty, doctor, dentist, clinic, hospital): Total Number of employees, students, children, teachers, residents, avg, attendance (race track, sport park, open-air stage): Number of: rooms (hotel/motel), bays (car wash), machines (laundry), car spaces (drive-in restaurant), inmates (jail or prison, visitors (picnic area, fairgrounds), campsites (campground): Number of parking spaces: Hours of operation: Number of shifts: Building are (square feet) for (retail sales, occupied space (excluding storage)): Restaurant area (square feet): Other use area (list use under remarks): Remarks:
